TN 11 (03-04)

NL 00705.358 Continuing Disability Review (CDR) Cessation Notice

Social Security Administration

Supplemental Security Income

Notice of Disability Cessation  

 

 

Date:  

Claim Number: 999-99-9999DC 

 

 

Jane Doe for

John Smith

Street Address

City ST ZIP 

 

IMPORTANT NOTICE

JOHN SMITH'S SSI WILL STOP 

 

Earlier we told you we were reviewing John Smith's case to see if he is still disabled under our rules. After reviewing all the information carefully, we have decided he no longer qualifies for Supplemental Security Income (SSI). 

 

We urge you to read this entire letter. It includes important information about appeal rights and medical assistance. It also explains how you can continue to receive payments if you appeal. 

 

The Decision On John Smith's Case 

 

The medical evidence shows that John Smith's health has improved and he no longer meets the disability requirements in (Month/Year). 

 

[Personalized Case Language (“PDN”)] 

 

When Payments Will Stop 

 

John Smith is no longer disabled under the definition of disability for children as of (Month/Year). He will get SSI for that month and the next 2 months as long as he continues to meet all other requirements until then. His last SSI payment will be for (Month/Year).  

 

See Next Page 

 

999-99-9999DC Page 2 of 5 

 

How To Appeal and Get Payments During the Appeal 

 

If you want to appeal and to get payments during the appeal, you have to act fast. You have to ask us within 10 days after the date you get this letter. The 10 days start when you get this letter. 

 

  • If you want to appeal, but do not want to ask for payments during the appeal, you have to ask us within 60 days after the date you get this letter. The 60days start when you get this letter.

  • We will assume you got this letter 5 days after the date at the top, unless you show us that it took longer for you to get it.

  • You have to ask us in writing to appeal and to get payments during the appeal. We will give you the forms you need to fill out. You can call us and we will mail the forms to you. Or, you can visit any Social Security Office to get the forms. We will tell you how to call us at the end of this letter.

  • If you are late and you want to appeal or ask for payments during the appeal, you should tell us why you were late. If we decide you have a good reason for being late, you will still be able to appeal or get payments during the appeal.

  • We can help you fill out the forms if you ask us. We will also need you to give us other information about John Smith's health problems.

 

Please read the enclosed pamphlet, “Your Right to Question the Decision to Stop Your Benefits.” It contains more information about the appeal.

Will You Have To Pay Back the Money You Get During the Appeal? 

 

If you get payments during the appeal and lose the appeal, we will ask you to pay back some or all of the money. If this happens, you can ask that you not have to pay us back. You will not have to pay us back if you cooperate with us during the appeal and we find that you need your money for your usual living expenses. If you ask us, we will give you more information about when you do not have to pay back the money. 

 

How An Appeal Works 

 

A Disability Hearing Officer will decide John Smith's SSI appeal. We will call this person a DHO in the rest of our letter. The DHO will meet with you before making the decision on the appeal. The meeting works like this. 

 

See Next Page 

 

999-99-9999DC Page 3 of 5 

 

  • The DHO will mail you a letter at least 20 days before the meeting to tell you its date, time and place.

  • You can look at John's file before the meeting.

  • You can tell the DHO the reasons you think John is still disabled. You should give the DHO any information you think is missing from his file. If you need help in getting the additional information, the DHO will help you. You can bring someone to represent you at the meeting. And you can bring people to explain the reasons he is disabled.

  • You can have the DHO order people to come to the meeting to speak about John's health problems and bring important papers. You can question these people at the meeting.

  • You do not have to go to the meeting in person. If you do not want to go, you can still give the DHO any more facts you may have. The DHO will decide the case using these facts, and what is now in the file. But if you go to the meeting, it may help the DHO decide the case.

 

If You Want Help With Your Appeal 

 

You can have a lawyer, friend, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. The local Social Security office has a list of groups that can help you with your appeal. 

 

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. 

 

If John Smith's Health Gets Worse 

 

If John Smith's health gets worse, please get in touch with us. He may be able to get SSI again. We can help you file a new application for SSI. 

 

You have the right to file a new application at any time, but filing a new application is not the same as appealing this decision. So, if you disagree with this decision, you should ask for an appeal within 60 days. 

 

 

See Next Page 

 

 

999-99-9999DC Page 4 of 5 

 

Information About Medical Assistance 

 

If John Smith is getting medical assistance from your State medical assistance agency, even though he will not get SSI, he may still qualify for medical assistance to help with health care bills. That's because many children may still qualify for medical assistance if they live in households that still meet the income and resources rules for SSI. 

 

The State medical assistance agency may contact you for information they need to make a decision about his medical assistance. If the agency decides that he is qualified to remain on medical assistance, his medical assistance benefits will continue, without a break in coverage. 

 

If the State medical assistance agency decides that he is not qualified to continue getting medical assistance, it must send you a separate letter and information about how to appeal that decision. If you get a letter that tells you that his medical assistance will stop, you should contact the State medical assistance agency right away. 

 

If you appeal that decision on time, he will continue to receive medical assistance until the agency decides the appeal. If you have not heard from them in 60 days from the date of this letter, you may want to contact your local medical assistance office or the [State] Department of Health Services. If you call or visit that office, please have this letter with you. 

 

You may also get help to pay for John Smith's health care bills through the Children's Health Insurance Program (CHIP) in your State. For more information about CHIP in your State, call toll-free 1-877-KIDS NOW, or 1-877-543-7669. 

 

If You Have Any Questions 

 

If you have any questions you may call us toll-free at 1-800-772-1213, or call your local Social Security office at [FO phone number from TRIDE]. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at: 

 

[Field Office Address

City, ST, ZIP] 

 

 

See Next Page 

 

999-99-9999DC Page 5 of 5

 

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly. 

 

 

(Signature)

Regional Commissioner 

 

Enclosure:

SSA Pub. No. 05-10090 

 

Cessation Notice

Fill-ins

IMPORTANT NOTICE

  1. SSI WILL STOP

     

Earlier we told you we were reviewing (2) case to see if (3) still disabled under our rules. After reviewing all the information carefully, we have decided (4) for Supplemental Security Income (SSI). 

 

We urge you to read this entire letter. It includes important information about appeal rights and medical assistance. It also explains how you can continue to receive payments if you appeal. 

 

  1. Choice 1: Recipient's name (possessive)

    Choice 2: Your 

     

  2. Choice 1: Recipient's name (possessive)

    Choice 2: Your 

     

  3. Choice 1: he is

    Choice 2: she is

    Choice 3: you are 

     

  4. Choice 1: he no longer qualifies

    Choice 2: she no longer qualifies

    Choice 3: you no longer qualify 

     

The Decision On (1) Case 

 

The medical evidence shows that (2) health has improved and (3) the disability requirements in (Month/Year). 

 

[Personalized Case Language (“PDN”)] 

 

  1. Choice 1: Recipient's name (possessive)

    Choice 2: Your 

     

  2. Choice 1: Recipient's name (possessive)

    Choice 2: your 

     

  3. Choice 1: he no longer meets

    Choice 2: she no longer meets

    Choice 3: you no longer meet 

     

When Payments Will Stop 

 

(1) no longer disabled under the definition of disability for children as of (Month/Year). (2) will get SSI for that month and the next 2 months as long as (3) to meet all other requirements until then. (4) last SSI payment will be for (Month/Year). 

 

  1. Choice 1: Recipient's name

    Choice 2: You 

     

  2. Choice 1: He

    Choice 2: She

    Choice 3: You 

     

  3. Choice 1: he continues

    Choice 2: she continues

    Choice 3: you continue 

     

  4. Choice 1: His

    Choice 2: Her

    Choice 3: Your 

     

How To Appeal and Get Payments During the Appeal

 

If you want to appeal and to get payments during the appeal, you have to act fast. You have to ask us within 10 days after the date you get this letter. The 10 days start when you get this letter. 

 

  • If you want to appeal, but do not want to ask for payments during the appeal, you have to ask us within 60 days after the date you get this letter. The 60 days start when you get this letter.

  • We will assume you got this letter 5 days after the date at the top, unless you how us that it took longer for you to get it.

  • You have to ask us in writing to appeal and to get payments during the appeal. We will give you the forms you need to fill out. You can call us and we will mail the forms to you. Or, you can visit any Social Security Office to get the forms. We will tell you how to call us at the end of this letter.

  • If you are late and you want to appeal or ask for payments during the appeal, you should tell us why you were late. If we decide you have a good reason for being late, you will still be able to appeal or get payments during the appeal.

  • We can help you fill out the forms if you ask us. We will also need you to give us other information about (1) health problems.

 

Please read the enclosed pamphlet, “Your Right to Question the Decision to Stop Your Benefits.” It contains more information about the appeal. 

 

  1. Choice 1: Recipient's name (possessive)

    Choice 2: your 

     

Will You Have To Pay Back the Money You Get During the Appeal? 

 

If you get payments during the appeal and lose the appeal, we will ask you to pay back some or all of the money. If this happens, you can ask that you not have to pay us back. You will not have to pay us back if you cooperate with us during the appeal and we find that you need your money for your usual living expenses. If you ask us, we will give you more information about when you do not have to pay back the money. 

 

How An Appeal Works 

 

A Disability Hearing Officer will decide (1) SSI appeal. We will call this person a DHO in the rest of our letter. The DHO will meet with you before making the decision on the appeal. The meeting works like this. 

 

  • The DHO will mail you a letter at least 20 days before the meeting to tell you its date, time and place.

  • You can look at (2) file before the meeting.

  • You can tell the DHO the reasons you think (3) still disabled. You should give the DHO any information you think is missing from (4) file. If you need help in getting the additional information, the DHO will help you. You can bring someone to represent you at the meeting. And you can bring people to explain the reasons (5) disabled.

  • You can have the DHO order people to come to the meeting to speak about (6) health problems and bring important papers. You can question these people at the meeting.

  • You do not have to go to the meeting in person. If you do not want to go, you can still give the DHO any more facts you may have. The DHO will decide the case using these facts, and what is now in the file. But if you go to the meeting, it may help the DHO decide the case. 

     

 

  1. Choice 1: Recipient's name (possessive)

    Choice 2: your 

     

  2. Choice 1: Recipient's first name (possessive)

    Choice 2: your 

     

  3. Choice 1: (Recipient's first name) is

    Choice 2: you are 

     

  4. Choice 1: his

    Choice 2: her

    Choice 3: your 

     

  5. Choice 1: he is

    Choice 2: she is

    Choice 3: you are

  6. Choice 1: Recipient's first name (possessive)

    Choice 2: your 

     

If You Want Help With Your Appeal 

 

You can have a lawyer, friend, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. The local Social Security office has a list of groups that can help you with your appeal. 

 

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. 

 

If (1) Health Gets Worse 

 

If (2) health gets worse, please get in touch with us. (3) may be able to get SSI again. We can help you file a new application for SSI. 

 

You have the right to file a new application at any time, but filing a new application is not the same as appealing this decision. So, if you disagree with this decision, you should ask for an appeal within 60 days. 

 

  1. Choice 1: Recipient's name (possessive)

    Choice 2: Your 

     

  2. Choice 1: Recipient's name (possessive)

    Choice 2: Your 

     

  3. Choice 1: He

    Choice 2: She

    Choice 3: You 

     

Information About Medical Assistance 

 

If (1) getting medical assistance from your State medical assistance agency, even though (2) will not get SSI, (3) may still qualify for medical assistance to help with health care bills. That's because many children may still qualify for medical assistance if they live in households that still meet the income and resources rules for SSI. 

 

The State medical assistance agency may contact you for information they need to make a decision about (4) medical assistance. If the agency decides that (5) qualified to remain on medical assistance, (6) medical assistance benefits will continue, without a break in coverage. 

 

If the State medical assistance agency decides that (7) not qualified to continue getting medical assistance, it must send you a separate letter and information about how to appeal that decision. If you get a letter that tells you that his medical assistance will stop, you should contact the State medical assistance agency right away. 

 

If you appeal that decision on time, (8) will continue to receive medical assistance until the agency decides the appeal. If you have not heard from them in 60 days from the date of this letter, you may want to contact your local medical assistance office or the [State] Department of Health Services. If you call or visit that office, please have this letter with you. 

 

You may also get help to pay for (9) health care bills through the Children's Health Insurance Program (CHIP) in your State. For more information about CHIP in your State, call toll-free 1-877-KIDS NOW, or 1-877-543-7669. 

 

  1. Choice 1: Recipient's name is

    Choice 2: you are

  2. (2) Choice 1: he

    Choice 2: she

    Choice 3: you 

     

  3. Choice 1: he

    Choice 2: she

    Choice 3: you 

     

  4. Choice 1: his

    Choice 2: her

    Choice 3: your 

     

  5. Choice 1: he is

    Choice 2: she is

    Choice 3: you are 

     

  6. Choice 1: his

    Choice 2: her

    Choice 3: your 

     

  7. Choice 1: he is

    Choice 2: she is

    Choice 3: you are 

     

  8. Choice 1: he is

    Choice 2: she is

    Choice 3: you are 

     

  9. Choice 1: Recipient's name

    Choice 2: your 

     

If You Have Any Questions 

 

If you have any questions you may call us toll-free at 1-800-772-1213, or call your local Social Security office at [FO phone number from TRIDE]. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at: 

 

[Field Office Address

City, ST, ZIP] 

 

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.  

 

 

(Signature)

Regional Commissioner 

 

Enclosure:

SSA Pub. No. 05-10090


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900705358
NL 00705.358 - Continuing Disability Review (CDR) Cessation Notice - 03/11/2004
Batch run: 01/27/2009
Rev:03/11/2004